Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to ensure that care and services were provided
in accordance with the manufacturer's instructions for use for an air loss mattress (specialized medical
mattress with internal air tubes and tiny holes that continuously circulate air to keep skin dry, cool, and
reduce pressure, preventing bedsores (pressure ulcers) by shifting pressure points) and facility staff were
trained and competent to use their air loss mattresses safely for one of two sampled residents (Resident
(RES)) 2, when RES 2 who had a history of a recent fall (12/9/25) while on an air loss mattress at the
facility. RES 2 weighed 124.4 pounds (lbs. -unit of weight measurement) and weight settings on the air loss
mattress indicated weight was set at 245 -285 lbs. The nurses assigned to RES 2 did not know what
pressure settings should be set on the air loss mattress, and there was no record of any training, education,
in-service or competency record for air loss mattress use for the nurses.These failures had the potential to
cause harm to RES 2 and other residents who used air loss mattresses and placed these residents at risk
for skin breakdown due to pressure injury, pain, increased risk for falls and decline in physical
functioning.During a review of RES 2's Physician Progress Note, dated 6/3/2025, the Physician Progress
Note indicated RES 2 was a [AGE] year-old Male with an initial admission date of 9/28/24 and was
readmitted to the facility on [DATE] for continuation of medical care. RES 2 had a past medical history of
[Traumatic Brain Injury (TBI - damage to the brain from a sudden jolt, blow, or penetrating injury to the
head, affecting brain function with mild to severe outcomes, ranging from temporary confusion to
permanent disability or death)] [status post (after)] [Ventriculoperitoneal Shunt (VPS -Thin, flexible, plastic
tube (called a catheter) that is placed under the skin to drain the extra fluid from brain and send it to belly to
prevent high pressures inside brain)] placement, [high blood pressure], and venous thromboembolism (a
serious condition involving a blood clot (thrombus) forming in a deep vein, most commonly in the legs). RES
2 was admitted to [Hospital A] on 05/22/2025 due to diaphoresis (sweating profusely), [shortness of breath]
and [high blood pressure]. RES 2 underwent extensive workup and was sent to the facility for acute
rehabilitation [high-intensity program designed to help people regain physical and thinking skills lost due to
a severe injury, illness, or surgery]. During a concurrent interview and record review on 1/7/26 at 2:40 p.m.
with the Nurse Unit Manager (NM), RES 2's medical record, undated was reviewed for recent falls. The NM
stated RES 2 had a fall on 12/9/25 with no injuries. The NM stated RES 2 was currently on-an air loss
mattress and she was unable to find the physician order for use of an air loss mattress for RES 2. The NM
stated RES 2 was on an air loss mattress at the time of the fall on 12/9/25 and the facility review did not
identify any issues with the settings or functionality of the air loss mattress at the time of the fall. The NM
stated the Interdisciplinary Care Conference note dated 12/10/25 at 11:59 a.m. indicated . IDT investigated
root cause: resident continues on air loss mattress, settings are correct and functioning well.During a
concurrent observation and
Residents Affected - Few
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
055573
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055573
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/07/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Kingsburg Center
1101 Stroud Ave
Kingsburg, CA 93631
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
interview on 1/7/26 at 3:00 p.m. in room RES-2's room with the NM, observed RES 2 on a bed with an air
loss mattress. The NM validated the settings on mattress were set at a maximum weight of 285 pounds.
The NM stated the air loss mattress was not set to the correct settings. NM stated RES 2 did not weigh 285
pounds. NM stated RES 2's weight on January 2, 2026, five days ago was 124.4 lbs. NM stated the air loss
mattress should be set according to the resident's weight. NM stated the therapeutic effect would be
affected by incorrect settings on the mattress and placed residents at risk for discomfort, pressure injuries
to skin and falls from the bed. During a concurrent observation and interview on 1/7/25 at 3:16 p.m. with
LVN 1 & the NM, observed RES 2's air loss mattress settings. LVN 1 stated she was assigned to RES 2
today. LVN 1 validated and stated the mattress settings were set at maximum settings of 285 lbs. LVN 1
stated she was unsure what the settings should be for RES 2. LVN 1 stated she would have to check
physician orders for the settings. LVN 1 stated she was not sure what RES2's weight was but stated RES2
did not appear to be 245-285 lbs. LVN 1 stated nurses were expected to check that air loss mattresses
were functioning properly each shift. During a concurrent interview and record review on 1/7/26 at 3:18 p.m.
with LVN 1 & the NM, RES 2's medical records, undated were reviewed for the physician order for air loss
mattress. LVN 1 stated that she was unable to find a physician's order for use of the air loss mattress and
order for settings of the air loss mattress for RES 2. LVN 1 stated and validated the weight in the medical
record and stated the most recent weight of RES 2 this week dated 1/2/26 was 124.4 lbs. LVN 1 stated that
setting the wrong weight on the air loss mattress was not acceptable and have the potential to cause
pressure injuries to skin and harm to the patient. LVN 1 stated that she was not aware that she should be
checking the weight settings on the air loss mattress and going forward she will make sure air loss
mattresses had the correct weight settings. LVN 1 stated as far as she was aware, use of an air loss
mattress required a physician order. During an interview on 1/7/26 at 3:37 p.m. with the Director of Staffing
Development (DSD), the DSD stated she was in charge of the staff training. The DSD stated she was
familiar with RES 2. The DSD stated RES2 was on an air loss mattress and required two people to assist
with turning and care. The DSD stated facility staff were trained on the use of air loss mattresses and it was
important to have the correct weight setting on the air loss mattress. The DSD stated that 245-285 lbs.
setting for a resident that only weighed 124.4 lbs. was not safe and was not aligned with instructions for
use. The DSD stated incorrect weight-based settings may have the potential to cause harm to the patients.
The DSD stated that Director of Nursing (DON) would be best to answer that question regarding weight
settings and expectations for nursing staff training.During an interview on 1/7/26 at 3:53 p.m. with the ADM,
the ADM stated he was familiar with RES 2. The ADM stated the fall on 12/9/25 for RES 2 was investigated
as per facility policy, no injuries were identified, and RES 2's care plan was updated as needed. The ADM
stated an air loss mattress use or settings on the air loss mattress were not identified as the cause for the
fall. The ADM stated that he was not sure if the physician order was required for use of an air loss mattress
and as far as he was aware, it was used as a nursing intervention. The ADM stated he would have to follow
up and check with his clinical staff about the requirement for an order for the use of air loss mattress. The
ADM stated RES 2 was on hospice care (a specialized, holistic support system for people with terminal
illnesses, focusing on comfort, dignity, and quality of life when a cure is not possible, rather than curative
treatment) and hospice nurse and physician was treating the patient. Requested to speak with director of
nursing (DON) and ADM stated that DON is out on leave due to unforeseen circumstances. Requested
training record for nurses assigned to RES 2 on the shift when fall occurred on 12/9/25 and LVN 1. The
ADM stated he would have to follow up with his team and submit via email.During a phone
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055573
If continuation sheet
Page 2 of 3
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055573
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/07/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Kingsburg Center
1101 Stroud Ave
Kingsburg, CA 93631
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
interview on 1/20/26 at 12:41 p.m. with the ADM, the ADM stated the facility did not have any policy for use
of an air loss mattress and the facility staff were expected to follow manufacturer's instructions for use. The
ADM stated he was made aware of the weight settings of 245-285 lbs. on RES 2's air loss mattress on
1/7/26 and agreed it was not set correctly. The ADM stated that the weight setting on the air loss mattress
was not aligned with the instructions for use. The ADM stated he was not able to comment on whether
setting an air loss mattress weight setting at 245-285 lbs. for a resident that weighs 124.4 lbs. had the
potential to cause harm to the patient. The ADM stated he was unaware of any harm caused to RES 2 that
were due to incorrect settings on the air loss mattress. The ADM stated the facility also did not have any
training records for LVN 1 on the use of an air loss mattress or RN 1, nurse assigned to RES 2 on 12/9/25
when RES2 had a fall. The ADM stated the DON is not available for interview at this time and was still out
on leave with a potential return date on [DATE]. The ADM stated the training for air loss mattress use could
be beneficial but the facility at this time did not have a policy requiring training on the air loss mattress use
or as an annual training requirement. During a phone interview on 1/20/26 at 3:33 p.m. with the DSD, the
DSD stated she was in charge of education and in-services and training at the facility. The DSD stated that
she worked with the DON and unit manager for nurse's training. The DSD stated and validated that she was
unable to find any training or in-service record that indicated nurse [RN 1] assigned to RES 2 on 12/9/25 at
the time of fall and LVN 1 assigned on 1/7/26 had received any in-service or training on air loss mattress
use. The DSD stated the last in-services for air loss mattress was completed on 6/27/25 and 12/17/25 of
last year. The DSD stated the in-service and training covered the settings on an air loss mattress and
should be set according to the resident's weight . During a review of the air loss mattress's instruction for
use provided by facility administrator (ADM), retrieved from https://vimeo.com/848769965, the instructions
for use indicated . to prepare the mattress for the resident turn the dial to the correct weight of the resident .
During a review of the document titled [model number], Low Air-Loss Mattress Replacement System With
Alternating Pressure User's Manual, undated, provided by [company name] customer service, the
document indicated . Intended Use Auto-pressure control Medical Air Mattress is designed for bed sore and
wound care therapy treatment and prevention, which may occur during an extended hospital stay and
nursing home/long term care environment . Warnings . refer to the manual before use and under proper
medical supervision. Improper operation of this system may cause damage to the product and possible
injury to the user . Do not use this product or any available optional equipment without first completely
reading and understanding this instruction manual. If you are unable to understand the warnings, cautions
or instructions, please contact a healthcare professional, dealer or authorized technician before attempting
to use this equipment, otherwise injury or damage may occur. Only qualified personnel trained in the
treatment and prevention of pressure injuries should operate this device . attention has to be paid to a
potential danger that requires correct procedures or practices in order to prevent personal injury . Close
supervision is necessary when this product is used by, on, or near children or persons with a disability .
Event ID:
Facility ID:
055573
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
FAQ · About this visit
Common questions about this visit
What happened during the January 7, 2026 survey of Kingsburg Center?
This was a inspection survey of Kingsburg Center on January 7, 2026. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Kingsburg Center on January 7, 2026?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.